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Despite his government’s well-earned reputation for consulting at length on the big issues, Prime Minister Justin Trudeau has shown he won’t hesitate to act unilaterally once he’s made up his mind.

In May, for instance, faced with opposition MPs who were delaying a vote in the House of Commons, the prime minister barged his way into the gaggle to break them up, delivering an inadvertent elbow in the process.

This week, he moved just as abruptly to pre-empt stalled negotiations over a national price on carbon, giving the provinces until 2018 to come up with plans of their own, or his government would do it for them.

Now Trudeau faces another protracted battle with the provinces over health care, a topic that’s bedevilled, tormented and harried every one of his immediate predecessors in the third-floor corner office of Parliament’s Centre Block.

Is he prepared to circumvent those discussions, too, in the face of demands from the premiers for more money with no strings attached?

The first signals are contained in letters the prime minister sent to the premiers just last week, in response to a demand they’d made in July for a first ministers’ meeting to discuss health care ahead of the planned December gathering on climate change.

“Together with predictable funding, the key to long-term sustainability lies in transforming how health care services are delivered,” Trudeau wrote to the premiers on Sept 28. He repeated that identical line in a follow-up letter dated Sept. 30.

As for that meeting on health care?

Trudeau writes that he’s looking forward to meeting them to discuss “a pan-Canadian framework for clean growth and climate change.”

It’s not exactly an elbow, but the message is just as pointed.

Health reform

There will be no increase in the amounts Ottawa sends to the provinces for health care, especially without an iron-clad guarantee that the money will be spent solely to improve health services.

That means the Trudeau government will stay with the Harper government’s decision to hold annual increases in health care transfers at three per cent, or the cost of living.

The provinces insist that’s not enough as populations age and demands on the system grow.

They’re helped by the federal NDP, who argue the Trudeau government is keeping the Harper “health care cuts” in place.

Politicians can endlessly debate the difference between a cut and reduced increases, but the one thing that is clear is that the Liberals aren’t budging in advance of the budget next spring.

Federal Health Minister Jane Philpott says that more money for cash-strapped provinces isn’t the only solution to problems with the health care system. (Darryl Dyck/Canadian Press)

“The discussion around the Canada Health Transfer is a financial discussion,” Health Minister Jane Philpott told reporters after cabinet on Tuesday. “As I’ve said before, I have no reason to believe that it will change from the current plan.”

That’s not the only thing Philpott’s had to say in the lead-up to her meeting with federal and provincial health ministers on October 18.

She’s told a university audience that Ottawa’s role in health is more than to “simply open up the federal wallet,” and that past health accords never tackled the need for fundamental reforms in health care services.

“We took the status quo and inflated it,” she said.

Strings attached

Translation: There will be strings attached to any new money the federal government earmarks for health.

Topping the list is home care. It was the centrepiece of the Liberals’ campaign platform, but they’ve yet to invest any of the promised $3 billion over four years.

The others are improved access to mental health services, more affordable prescription drugs and innovation.

Philpott calls them “shared priorities” and that’s true. But the issue for the provinces is Ottawa’s diminishing share of spending.

“We want to get back to a funding formula that sees the federal contribution rise above the 22 per cent share they now provide,” said one provincial government contact.

The Canada Health Transfer was $34 billion last year. Total health care spending was about $155 billion.

The provinces want the federal share to increase to at least 25 per cent.

But some provinces, particularly Quebec, reject any attempt by the federal government to dictate how they spend on health care.

‘Talking about conditions is their way of not talking about funding.’– Gaetan Barrette, Quebec Health Minister

“Talking about conditions is their way of not talking about funding,” Gaetan Barrette, the province’s health minister, told reporters in Ottawa last week. “We are all trapped and we are all talking about conditions, with strings attached, with strings loosely attached, or tightly attached, whatever.”

How far are the provinces prepared to go to make their case?

One far-fetched idea floated by a provincial official is that the premiers could express their displeasure by refusing to attend that December climate change meeting.

Others see the two issues as entirely separate.

That’s how the federal Liberals see it, too.

Health care is too important, the shared jurisdiction between Ottawa and the provinces too clearly drawn for either side to have much leverage against the other to force an agreement.

For now, the two sides will wait to see what comes out of the meeting of health ministers later this month.

In his letter of September 28 Trudeau wrote that he’s looking forward to the successful conclusion of a new five-year health accord that will create “a more adaptable, innovative and affordable health system for all Canadians.”